At CVS Health, we’re building a world of health around every consumer and surrounding ourselves with dedicated colleagues who are passionate about transforming health care. As the nation’s leading health solutions company, we reach millions of Americans through our local presence, digital channels and more than 300,000 purpose-driven colleagues – caring for people where, when and how they choose in a way that is uniquely more connected, more convenient and more compassionate. And we do it all with heart, each and every day. **Position Summary** This is a full-time remote opportunity. Working schedule is _Monday through Friday, 8:00 AM -5:00 PM Eastern Standard Time (EST)_ with flexibility to work outside of business hours, as needed. This position reports to the Potential Quality of Care (PQOC) nurse investigator team manager. This position is responsible for the review and evaluation of protected clinical information and documentation. The PQOC team reviews documentation and interprets data obtained from clinical records or systems to apply appropriate clinical criteria and policies in line with regulatory and accreditation requirements for member and/or provider issues. Applies specialized clinical knowledge to participate in quality improvement efforts to assess and enhance patient care. Collaborates with the healthcare quality team to collect and analyze clinical data, participate in quality reviews, and identify opportunities for process improvement. Provides insights and recommendations to optimize healthcare practices and promote patient safety and satisfaction. _Additional responsibilities to include but not limited to the following:_ - Works Potential Quality of Care cases (Medical), along with Patient Safety Events across all lines of business (Commercial, Medicare, and Medicaid). Independently coordinates the clinical resolution with internal/external clinician support as required. - Reviews documentation and evaluates Potential Quality of Care issues based on clinical policies and benefit determinations. - Considers all documented system information as well as any additional records/data presented to develop a determination or recommendation. - Data gathering requires navigation through multiple system applications. - Staff may be required to contact the providers of record, vendors, or internal Aetna departments to obtain additional information. - Evaluates documentation/information to determine compliance with clinical policy, regulatory and accreditation guidelines. - Accurately applies critical thinking skills in addition with team based decision rubric to assure case is reviewed by a practitioner with clinical expertise for the issue at hand. - This position commands a comprehensive knowledge of complex delegation arrangements, contracts (member and provider), clinical criteria, benefit plan structure, regulatory requirements, company policy and other processes which are required to support the review of the clinical documentation/information. - Condenses complex information into a clear and precise clinical picture while working independently. - Reports clinical findings to appropriate staff or others in order to ensure appropriate outcome and/or follow-up for improvement as indicated. - The incumbent must demonstrate strong clinical judgement as well as knowledge of internal systems. **Required Qualifications** - Registered Nurse (RN) with current unrestricted compact license and willing to obtain additional licensure as needed. - 3 years of clinical experience required. - 2 years’ experience using personal computer, keyboard navigation, navigating multiple systems and applications; and using MS Office Suite applications (Teams, Outlook, Word, Excel, etc.) **Preferred Qualifications** - Emergency/critical care experience - Experience working Grievance cases - Case Management or Utilization Management experience - Managed care experience - Medicaid experience - Systems experience: ATV, GPS, MedCompass, QNXT, Dynamo, MedHok - Critical thinking skills - Previous experience working in a remote/virtual environment - Preference for those in EST or CST zones. - Bachelor's of Science in Nursing **Education** Associates or Diploma nursing degree required. **Anticipated Weekly Hours** 40 **Time Type** Full time **Pay Range** The typical pay range for this role is: $54,095.00 - $116,760.00 This pay range represents the base hourly rate or base annual full-time salary for all positions in the job grade within which this position falls. The actual base salary offer will depend on a variety of factors including experience, education, geography and other relevant factors. This position is eligible for a CVS Health bonus, commission or short-term incentive program in addition to the base pay range listed above. Our people fuel our future. Our teams reflect the customers, patients, members and communities we serve and we are committed to fostering a workplace where every colleague feels valued and that they belong. **Great benefits for great people** We take pride in our comprehensive and competitive mix of pay and benefits – investing in the physical, emotional and financial wellness of our colleagues and their families to help them be the healthiest they can be. In addition to our competitive wages, our great benefits include: + **Affordable medical plan options,** a **401(k) plan** (including matching company contributions), and an **employee stock purchase plan** . + **No-cost programs for all colleagues** including wellness screenings, tobacco cessation and weight management programs, confidential counseling and financial coaching. + **Benefit solutions that address the different needs and preferences of our colleagues** including paid time off, flexible work schedules, family leave, dependent care resources, colleague assistance programs, tuition assistance, retiree medical access and many other benefits depending on eligibility. For more information, visit https://jobs.cvshealth.com/us/en/benefits We anticipate the application window for this opening will close on: 08/22/2025 Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state and local laws. We are an equal opportunity and affirmative action employer. We do not discriminate in recruiting, hiring, promotion, or any other personnel action based on race, ethnicity, color, national origin, sex/gender, sexual orientation, gender identity or expression, religion, age, disability, protected veteran status, or any other characteristic protected by applicable federal, state, or local law.